Development of a Decision Aid for Family Surrogate Decision Makers of Critically Ill Patients Requiring Renal Replacement Therapy in ICU: User-Centered Design for Rapid Prototyping.

Objectives Renal replacement therapy (RRT) is increasingly adopted for critically ill patients diagnosed with acute kidney injury, but the optimal time for initiation remains unclear and prognosis is uncertain, leading to medical complexity, ethical conflicts, and decision dilemmas in intensive care unit (ICU) settings. This study aimed to develop a decision aid (DA) for family surrogate of critically ill patients to support their engagement in shared decision-making process with clinicians. Methods Development of DA employed a systematic process with user-centered design (UCD) principle, which included: (i) competitive analysis: searched, screened, and assessed the existing DAs to gather insights for design strategies, developmental techniques, and functionalities; (ii) user needs assessment: interviewed family surrogates to explore target user group's decision-making experience and identify their unmet needs; (iii) evidence syntheses: integrate latest clinical evidence and pertinent information to inform the content development of DA.Results The competitive analysis included 16 relevant DAs, from which we derived valuable insights from existing resources. User decision needs were explored among a cohort of 15 family surrogates, revealing four thematic issues in decision-making, including stuck into dilemmas, sense of uncertainty, limited capacity, and delayed decision confirmation. A total of 27 articles were included for evidence syntheses. Relevant decision-making knowledge on disease and treatment, as delineated in the literature sourced from decision support system or clinical guidelines, were formatted as the foundational knowledge base. Twenty-one items of evidence were extracted and integrated into the content panels of benefits and risks of RRT, possible outcomes, and reasons to choose. The DA was drafted into a web-based phototype using the elements of UCD. This platform could guide users make preparation of decision-making through a sequential four-step progress: identifying treatment options, weighing the benefits and risks, clarifying personal preferences and values, and formulating a schedule for formal shared decision-making with clinicians.Conclusions We developed a rapid prototype of DA tailored for family surrogate decision makers of critically ill patients in need of RRT in ICU setting. Future studies are needed to evaluate its usability, feasibility, and clinical effects of this intervene.

A cohort autopsy study defines COVID-19 systemic pathogenesis.

Severe COVID-19 disease caused by SARS-CoV-2 is frequently accompanied by dysfunction of the lungs and extrapulmonary organs. However, the organotropism of SARS-CoV-2 and the port of virus entry for systemic dissemination remain largely unknown. We profiled 26 COVID-19 autopsy cases from four cohorts in Wuhan, China, and determined the systemic distribution of SARS-CoV-2. SARS-CoV-2 was detected in the lungs and multiple extrapulmonary organs of critically ill COVID-19 patients up to 67 days after symptom onset. Based on organotropism and pathological features of the patients, COVID-19 was divided into viral intrapulmonary and systemic subtypes. In patients with systemic viral distribution, SARS-CoV-2 was detected in monocytes, macrophages, and vascular endothelia at blood-air barrier, blood-testis barrier, and filtration barrier. Critically ill patients with long disease duration showed decreased pulmonary cell proliferation, reduced viral RNA, and marked fibrosis in the lungs. Permanent SARS-CoV-2 presence and tissue injuries in the lungs and extrapulmonary organs suggest direct viral invasion as a mechanism of pathogenicity in critically ill patients. SARS-CoV-2 may hijack monocytes, macrophages, and vascular endothelia at physiological barriers as the ports of entry for systemic dissemination. Our study thus delineates systemic pathological features of SARS-CoV-2 infection, which sheds light on the development of novel COVID-19 treatment.

Chinese Trauma Surgeon Association for management guidelines of vacuum sealing drainage application in abdominal surgeries-Update and systematic review.

Vacuum sealing drainage (VSD) is frequently used in abdominal surgeries. However, relevant guidelines are rare. Chinese Trauma Surgeon Association organized a committee composed of 28 experts across China in July 2017, aiming to provide an evidence-based recommendation for the application of VSD in abdominal surgeries. Eleven questions regarding the use of VSD in abdominal surgeries were addressed: (1) which type of materials should be respectively chosen for the intraperitoneal cavity, retroperitoneal cavity and superficial incisions? (2) Can VSD be preventively used for a high-risk abdominal incision with primary suture? (3) Can VSD be used in severely contaminated/infected abdominal surgical sites? (4) Can VSD be used for temporary abdominal cavity closure under some special conditions such as severe abdominal trauma, infection, liver transplantation and intra-abdominal volume increment in abdominal compartment syndrome? (5) Can VSD be used in abdominal organ inflammation, injury, or postoperative drainage? (6) Can VSD be used in the treatment of intestinal fistula and pancreatic fistula? (7) Can VSD be used in the treatment of intra-abdominal and extra-peritoneal abscess? (8) Can VSD be used in the treatment of abdominal wall wounds, wound cavity, and defects? (9) Does VSD increase the risk of bleeding? (10) Does VSD increase the risk of intestinal wall injury? (11) Does VSD increase the risk of peritoneal adhesion? Focusing on these questions, evidence-based recommendations were given accordingly. VSD was strongly recommended regarding the questions 2-4. Weak recommendations were made regarding questions 1 and 5-11. Proper use of VSD in abdominal surgeries can lower the risk of infection in abdominal incisions with primary suture, treat severely contaminated/infected surgical sites and facilitate temporary abdominal cavity closure.

Performance of cardiopulmonary resuscitation during prolonged basic life support in military medical university students: A manikin study.

BACKGROUND: The quality of chest compressions can be significantly improved after training of rescuers according to the latest national guidelines of China. However, rescuers may be unable to maintain adequate compression or ventilation throughout a response of average emergency medical services because of increased rescuer fatigue. In the present study, we evaluated the performance of cardiopulmonary resuscitation (CPR) in training of military medical university students during a prolonged basic life support (BLS). METHODS: A 3-hour BLS training was given to 120 military medical university students. Six months after the training, 115 students performed single rescuer BLS on a manikin for 8 minutes. The qualities of chest compressions as well as ventilations were assessed. RESULTS: The average compression depth and rate were 53.7±5.3 mm and 135.1±15.7 compressions per minute respectively. The proportion of chest compressions with appropriate depth was 71.7%±28.4%. The average ventilation volume was 847.2±260.4 mL and the proportion of students with adequate ventilation was 63.5%. Compared with male students, significantly lower compression depth (46.7±4.8 vs. 54.6±4.8 mm, P<0.001) and adequate compression rate (35.5%±26.5% vs. 76.1%±25.1%, P<0.001) were observed in female students. CONCLUSIONS: CPR was found to be related to gender, body weight, and body mass index of students in this study. The quality of chest compressions was well maintained in male students during 8 minutes of conventional CPR but declined rapidly in female students after 2 minutes according to the latest national guidelines. Physical fitness and rescuer fatigue did not affect the quality of ventilation.

The role of glioma stem cells in glioma tumorigenesis.

Malignant gliomas, the most common type of primary brain tumor, account for 80% of malignant tumors in the central nervous system (CNS). There are three principal types of glioma: astrocytomas, oligodendrogliomas, and oligoastrocytomas. Glioma stem cells (GSCs) have been found in all types; however, many fundamental questions about GSCs remain unanswered. This review will examine the current state of knowledge regarding GSC origin and the signaling pathways implicated in GSC tumorigenesis. The outstanding challenges for the study of GSCs in the context of glioma progression will also be discussed.

[Neuropsychological study of false memory in patients with amnesia mild cognitive impairment].

OBJECTIVE: To explore the profile of false memory in aMCI (amnesia mild cognitive impairment) and to elucidate the neuropsychological mechanism of false memory. METHODS: False memory provoked by pictures and feeling-of-knowing (FOK) test in episodic memory (EM) were conducted in 25 aMCI patients at our hospital from October 2009 to May 2010. And 25 age and education level-matched healthy patients were recruited into the healthy control (HC) group. RESULTS: As compared with HC group, the rate of false memory was higher in the aMCI group. The rate of false memory in recall stage was 26% ± 7% and that of questionnaire stage 28% ± 12%. And the difference between two group was significant (t = 14.437, 7.597, P < 0.05). The FOK-EM of correct judgment and false recognition in the aMCI group (41% ± 10%) was higher than the HC group. And the difference was significant (t = 4.207, P < 0.05). The rates of false memory in recall and questionnaire stages were positively correlated with FOK-EM in aMCI group (r = 0.563, 0.705, P < 0.01). CONCLUSION: The aMCI patients tend to have more false memory provoked by pictures. The deficit of memory monitoring in aMCI may be the foundation of false memory.

Traditional Chinese herb Dihuang Yinzi (DY) plays neuroprotective and anti-dementia role in rats of ischemic brain injury.

AIM OF THE STUDY: Traditional Chinese herb Dihuang Yinzi (DY) is well known to treat neurological diseases by traditional Chinese medical practitioners. This study is to elucidate its neuroprotective and anti-dementia role in ischemic brain injury. MATERIALS AND METHODS: The effects of DY on the pathohistological changes, lactate dehydrogenase (LDH) release, Morris water maze task, expression of synaptophysin (SYP) and extracellular signal-regulated protein kinase (ERK) of hippocampi of rats with ischemic brain injury were investigated. RESULTS: This study showed that DY not only significantly decreased the number of TUNEL-positive cells but also reduced the LDH release of hippocampus of model rat. Morris water maze test showed that the ability of learning and memory of rats dramatically impaired after ischemic brain injury. However, DY ameliorated the impairment of learning and memory of ischemic rats. Furthermore, western blotting and immunohistochemical data showed that the expression of extracellular regulated protein and synaptophysin, which correlates with synaptic formation and function, decreased after ischemic insult. However, DY inhibited the reduction of ERK an SYP expression in a dose-dependent way. CONCLUSION: These results suggest that DY possesses neuroprotective and anti-dementia properties, at least in part, by preventing the loss of neural cells and synapses in ischemic brain injury.

Antitumor efficiency of the cytosine deaminase/5-fluorocytosine suicide gene therapy system on malignant gliomas: an in vivo study.

BACKGROUND: Suicide gene therapy, particularly that utilizing the cytosine deaminase/5-fluorocytosine (CD/5-FC) system, represents a novel and attractive methodology of cancer research. Mechanistically, the CD enzyme can convert the antifungal agent 5-FC into the antimetabolite agent 5-fluorouracil (5-FU), thereby killing tumor cells. The purpose of this study was to investigate the antitumor efficiency of the CD/5-FC system in malignant gliomas using a nude mouse model. MATERIAL/METHODS: The eukaryotic expression plasmid pCMV-CD was transfected into U251 malignant glioma cells. Resistant clones (labeled U251/CD cells) were subsequently isolated and further confirmed by reverse transcription polymerase chain reaction (RT-PCR), immunofluoroscence, and immunoblot. Then U251/CD cells were incubated with 5-FC at various concentrations to measure viability ratios as determined by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) method. 5-FU concentrations in the media were measured by high-performance liquid chromatography (HPLC). Finally, the volumes and weights of tumors from glioma-bearing nude mice after 5-FC intervention were evaluated. RESULTS: The results revealed that the untreated U251 cells were insensitive to 5-FC whereas the U251/CD cells were highly sensitive. Apoptosis and cell death were observed on the U251/CD cells after 5-FC administration. HPLC analysis showed that 5-FU was detected in the U251/CD cell media. These in vivo animal data showed that the volumes and weights of the implanted tumors were dramatically decreased due to cell apoptosis and tumor necrosis. CONCLUSIONS: The in vivo results encourage a further investigation in a controlled trial on the treatment of malignant gliomas via the CD/5-FC gene therapy system.

STAT3 silencing with lentivirus inhibits growth and induces apoptosis and differentiation of U251 cells.

Glioblastoma multiforme (GBM), the most common type of central nervous system tumor in humans, is highly proliferative and resistant to apoptosis associated with genetic mutations that deregulate cell cycle. Signal transduction and activation of transcription 3 (Stat3) is a key signal transduction protein that mediated signaling by cytokines and contributed to oncogenesis. It is constitutively activated in numerous cancers including glioblastoma. To determine the effect on proliferation and differentiation of glioblastoma U251 cells after inhibiting STAT3 expression by RNAi, STAT3 gene was silenced with lentivirus vector in U251 cells. We demonstrate that a lentivirus-based shRNA vector had highly infecting efficiency to U251 cells and lentivirus vector-mediated RNAi significantly suppressed Stat3 expression and activation in U251 cells. Knockdown of STAT3 expression by RNAi suppressed the growth and induced apoptosis of U251 cells by down-regulating expression of Bcl-2. It was found that the cell proportion of G0/G1 phase significantly increased after silencing Stat3 by down-regulating expression of cyclin D1. Knockdown of Stat3 also induces morphological changes of U251 cell. It increases significantly expression of myelin basic protein (MBP) in U251 cells. This study demonstrates that STAT3 silencing with lentivirus effectively inhibits STAT3 gene expression and activation. Stat3 is associated with the survival, growth and differentiation of U251 cells. Lentivirus vector-mediated RNAi may be serve as a novel therapeutic strategy for treatment of GBM with expression constitutively and activation of STAT3 gene.